Adverse pregnancy outcome in Gestational Diabetes Mellitus (GDM)
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Transcript of Adverse pregnancy outcome in Gestational Diabetes Mellitus (GDM)
Adverse Pregnancy Outcome Of GDM
Dr . YASMIN AKTAR
MD Phase-B Resident Department of Endocrinology
BSMMU
Gestational diabetes mellitus (GDM)
It is defined as any degree of glucose intolerance with onset or first recognition during pregnancy, whether or not the condition persisted after pregnancy, and not excluding the possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy
Incidence
3 to 15% of all pregnancies are complicated by diabetes
0.2% to 0.5% of all pregnancies occur in women with pre-existing diagnosis of type 1 DM
similar number has pre-existing type 2 DM
Pathophygiology
Insulin resistance
Production of placental Somatomamotropin
Increased production of cortisol, estriol, progesterone
Increased insulin destruction by kidney & placenta
Increased lipolysis
Mother uses fat for her caloric needs
& serves glucose for fetal needs Changes of gluconeogenesis
Fetus preferentially utilizes alanine & other amino acids deprivng the mother of major neoglucogenic source
White classification
Based on maternal and obstetric risk factors, graded from A (best) to F (worst) designed to predict pregnancy outcomes
1971 and further updated in 1980 to incorporate ischemic heart disease and renal transplantation
Criteria for GDM(ADA)
Test 75 gm OGTT Measurement
Plasma glucose
Fasting ≥ 5.1mmol/L 1h ≥ 10.0 mmol/L 2h ≥ 8.5 mmol/L
WHO recommended 75gm OGTT criteria for GDM
Time point of OGTT Glucose values (mmol/L)
0 hour ≥ 6.102 hour ≥7.8
(Satisfying both or any of these values)
GDM risk assessment: ascertain at 1st ANC
Low risk
Age < 25 yrs
No known DM in 1st degree relative
Weight normal before pregnancy
Weight normal at birth
No hx. Of abnormal glucose metabolism
No history of poor obstetrics outcome
Average risk :
Perform blood glucose testing at 24-28 wks using:
One-step procedure: Diagnostic OGTT on all subjects
High-risk:
Perform blood glucose testing as soon as feasible :
Maternal age >35 yrs
BMI >30kg/m2
Strong FH. of type II DM
Previous Hx. Of : GDM, impaired glucose metabolism, or glucosuria
If GDM is not Dx. repeated at 24-28 wks or at any time a pt. has a symtoms or signs suggestive of hyperglycemia
Adverse outcome
Newborn baby
Related to fetus Macrosomia (> 4kg, 20–30% of infants
whose mothers have GDM)
FBS > 105 mg/ dl
Maternal hyperglycemia
Fetal hyperglycemia
Fetal hyperinsulinemia
Excessive Fetal growth & adiposity
Macrosomic baby Normal baby
Related to fetus cont……… Shoulder dystocia or birth injury Stillbirth Perinatal mortality Congenital malformation ( women with
fasting hyperglycemia ) Polycythemia (Hyperglycemia is a
stimulus for erythropoietin production)
Related to neonate
Hypoglycemia(maternal hyperglycemia
causing fetal hyperinsulinemia)-<1.7mmol/l Hyperbilirubinemia- ≥20mg/dl Hypocalcemia Intensive neonatal care RDS Neonatal death
Long-term complications
Increased risk of glucose intolerance Diabetes
Obesity
Related to mother
Preeclampsia(≥140mmhg SBP or ≥90 DBP + proteinuria- + or more or UTP-≥300mg/dl)
Hypertension(related to insulin resistance) Premature delivery Ketoacidosis Urinary and genital tract infections
Related to mother
Polyhydramnios
Increased risk of cesarean delivery
Increased risk of developing diabetes after pregnancy
Management of gestational diabetes Initial management is with diet and
exercise women with GDM need to be taught to
SMBG and perform daily tests fasting and 1 - hour after meals
If glycemic targets are not met within 2 weeks antidiabetic therapy is required
Maternal assessment
BP Wt A/E-for hydromnios, fetal growth Urine for glucose,protein & pus cell
Fetal assessment
USG
macrosomia
polyhydromnios Fetal monitoring
Fetal kick count
NST
BPL
Time of delivery
Duration of pregnancy Control of diabetes Presence of complications-
PIH,macrosomia Past obstetrics history Tests o fetal well being
Mode of delivery
Parity Bishop’s score of cervix Adequacy of pelvis Estimated fetal wt or macrosomia Associated maternal & fetal complication
Postnatal management Breastfeeding
Prevent hypoglycemia
Reduce insulin requrement by 25%
Diabetes following GDM screening &
Prevention
Women with GDM are at increased risk of developing diabetes
Risk factors:
• Family origin with high prevalence of diabetes (e.g. South Asian, Afro- Caribbean, Middle Eastern)
• Treatment with insulin in pregnancy;
• Maternal obesity
• Weight gain postpartum &
• Family h/o diabetes
Acknowledgement
THANK YOU